PA/MND Review of Spine Surgery services Questions & Answers 1. What is the Musculoskeletal Program? Horizon BCBSNJ has expanded our Pain Management Program with evicore to include Pain Management and Spine Surgery services all of which are now referred to as the Musculoskeletal Program. 2. What services does evicore perform under this expanded collaboration? For Spine Surgery services, evicore provides Utilization Management (UM) review (through either a PA/MND review), First Level UM appeals processing and UM-related Customer Service support. 3. What is the Musculoskeletal Program s claims process for Spine Surgery services? Professional claims for Spine Surgery services will suspend for medical necessity review by evicore. If a PA/MND has not been performed previously, a review will be done in accordance with the clinical guidelines adopted by Horizon BCBSNJ. After the medical necessity review is complete, evicore will return the suspended claim to Horizon BCBSNJ with a recommendation to pay or deny the services. Horizon BCBSNJ will process the claims according to the member s benefits and will continue to handle claim inquiries from both the member and health care professional. Disclaimer: The PA/MND does not supersede member benefits. An authorization does not guarantee payment of services. 4. How does evicore manage Spine Surgery services? evicore reviews PA/MND requests in accordance with the clinical guidelines adopted by Horizon BCBSNJ. 5. What Horizon BCBSNJ products are included in this program? For services rendered in New Jersey, the program will apply to: Horizon HMO Horizon Direct Access (DA) Horizon EPO Indemnity/Traditional OMNIA SM Health Plans Horizon POS Horizon PPO Note: This program does not apply to the Federal Employee Program 1
(FEP ), the State Health Benefits Program (SHBP), the School Employees' Health Benefits Program (SEHBP), Medicare Advantage, Medigap, Medicaid or Dual-Eligible Special Needs (DSNP) plans. 6. Are the SHBP and SEHBP participating in the PA/MND review of Spine Surgery services? No. PA/MND review of Spine Surgery services for SHBP/SEHBP members is not part of this program. Health care professionals should call Horizon BCBSNJ s Physician Services at 1-800-624-1110 for PA/MND review of Spine Surgery services for SHBP/SEHBP members. 7. What was the effective date for PA/MND of Spine Surgery services? PA/MND of Spine Surgery services was effective November 1, 2016. Participating and nonparticipating Horizon BCBSNJ health care professionals must continue to contact evicore directly for PA/MND review requests. 8. Who should be contacted for Pain Management and Spine Surgery procedure codes not managed by evicore? Health care professionals should call Horizon BCBSNJ s Physician Services at 1-800-624-1110. Members should call Member Services at the number on the back of their Horizon BCBSNJ identification card for benefit verification. Health care professionals 9. What is the Prior Authorization & Medical Necessity Determination (PA/MND) process for Spine Surgery services? The PA/MND process requires participating and nonparticipating health care professionals to request a review for any proposed course of treatment involving Spine Surgery services. Health care professionals should always contact evicore to obtain a PA/MND prior to rendering services to ensure that the proposed services are medically necessary and therefore will be covered by the plan. If a PA/MND is not obtained, claims may be delayed or denied pending our receipt of the information needed to establish medical necessity. There are three possible outcomes as a result of the PA/MND review: 1. Approved: the complete treatment requested meets the criteria for medical necessity. 2. Partial Approval: only a part of the treatment requested is approved and the remainder is denied. 3. Denied: the complete treatment does not meet clinical criteria and is denied. 2
For Inpatient Admissions: PA is required as determined by the member s benefits. For Outpatient Services: PA is required as determined by the member s benefits. Where member benefits do not require a PA, a pre- or post-service MND review will apply. 10. What Spine Surgery services need PA/MND determination? There are specific Spine Surgery services included in this program. Please refer to the List of Spine Surgery Codes subject to medical necessity and appropriateness review posted on the Spine Surgery tab of HorizonBlue.com/musculoskeletal. 11. How often is the Spine Surgery services list updated? The list is updated as necessary. When calling for a PA/MND review request, please check the List of Spine Surgery Codes subject to medical necessity and appropriateness review posted on the Spine Surgery tab of HorizonBlue.com/musculoskeletal. 12. Where are the Spine Surgery guidelines located for members enrolled in plans that have elected to participate in the Musculoskeletal Program? To access the Spine Surgery guidelines evicore uses to make Prior Authorization and Medical Necessity Determination decisions, please visit www.evicore.com/horizonspinesurgery. A link to this information is also included on the Spine Surgery tab of HorizonBlue.com/musculoskeletal. 13. Where are Horizon BCBSNJ s Medical Policy guidelines for Spine Surgery services located for members enrolled in plans that have NOT elected to participate in the Musculoskeletal Program? Horizon BCBSNJ s Medical Policy guidelines for Spine Surgery services for members enrolled in plans that have NOT elected to participate in the Musculoskeletal Program can be found within our online Medical Policy Manual on HorizonBlue.com/medicalpolicy. 14. Where are Spine Surgery services administered for this program? The Spine Surgery services can be administered at an: Inpatient facility Outpatient facility 1 Ambulatory surgical center 1 evicore will not perform PA/MND reviews for Spine Surgery services administered in an observation room or Emergency Room. 3
15. How has Horizon BCBSNJ educated health care professionals about the need for PA/MND review of Spine Surgery services? Horizon BCBSNJ has educated health care professionals by: Making an announcement within the News section of HorizonBlue.com/providers (accessible also through NaviNet ) 90 days prior to the program s effective date, which was November 1, 2016. This announcement was made on August 1, 2016. Posting Musculoskeletal Program information on HorizonBlue.com/musculoskeletal. Information includes additional reference materials such as the Quick Reference Guide (QRG) and List of Spine Surgery services. Making announcements in February 2017 advising health care professionals of the application of medical policies by evicore for members whose plans have elected to participate in the Musculoskeletal Program. If a pre-service PA/MND has not been performed for Spine Surgery services after the effective date of November 1, 2016, those services may be subjected to a post-service MND review prior to claims being paid for those services. 16. Are all Spine Surgery services currently administered by Horizon BCBSNJ included in the new Musculoskeletal Program administered by evicore? The program includes the entire range of Spine Surgery services that are performed in New Jersey by New Jersey participating and nonparticipating health care professionals for in-scope Horizon BCBSNJ fully- and selfinsured products and members. Contiguous county rules will apply only to Horizon BCBSNJ members living in the state of New Jersey that see a health care professional who is contracted with both Horizon BCBSNJ and the plan in which the health care professional is located. Note: ITS Home and ITS Host claims are not included, or are out of scope for the Musculoskeletal Program. However, Horizon BCBSNJ will maintain the administration of medical necessity reviews for the self-insured Administrative Services Only (ASO) employer groups that have not elected to participate in the Musculoskeletal Program. Prior Authorization/Medical Necessity Determination (PA/MND) 17. When should a health care professional obtain a PA/MND? A health care professional should obtain a PA/MND upon determining the patient s treatment plan for a Spine Surgery service. It s important that PA/MND is obtained prior to delivery of the services to ensure coverage. 4
Services that are considered not medically necessary when reviewed on a post-service basis will not be covered or reimbursed by Horizon BCBSNJ. 18. How does a health care professional initiate a PA/MND? A rendering or ordering participating health care professional can initiate a PA/MND review by: Visiting evicore s secure website at www.evicore.com. Calling evicore directly at 1-866-241-6603, Monday through Friday, 7 a.m. to 7 p.m., Eastern Time (ET). Multiple requests can be handled with one call. Urgent requests must be initiated by phone and identified as urgent by calling 1-866-241-6603. Representatives are available after hours and on weekends. Nonparticipating health care professionals may initiate a PA/MND review by calling 1-866-241-6603, Monday through Friday, 7 a.m. to 7 p.m., ET. The website is not available to nonparticipating health care professionals or for urgent requests. 19. Will a health care professional be able to initiate a PA/MND review via fax? No. Requests should be initiated online or by phone (see A18). 20. What clinical information is necessary to obtain a PA/MND review? Clinical information required for evicore to make a determination on a particular Spine Surgery service is available at www.evicore.com/horizonspinesurgery. 21. What information should health care professionals have available to initiate the PA/MND review? The health care professional should have the following information: Ordering health care professional name, address and office telephone number Rendering health care professional name, address and office telephone number (if different from ordering health care professional) Rendering facility name, NPI, Tax Identification Number (TIN), address and fax number Member name, date of birth and ID number Anticipated start date of treatment Member height, weight and body surface area Procedure Code and Description Diagnosis (ICD-10 code) Past therapeutic failures including physical therapy, interventional pain procedures, medications and any other conservative treatment 5
When applicable, co-surgeon information: name, Federal Tax Identification Number (FTIN), participation status with Horizon BCBSNJ Relevant Diagnostic/Imaging results 22. Will additional information be requested from the health care professional? Yes. Additional information may be requested depending on the Spine Surgery services, such as: Office encounter records, including clinical notes Operative/Procedure report(s) Report(s) of X-rays and high tech imaging; e.g., CT, MRI, nuclear medicine studies and myelography Relevant laboratory test results Pathology reports The health care professional should be prepared to fax the additional necessary documents to evicore s fax at 1-800-649-4548. 23. Can the ordering/rendering health care professional request a Peerto-Peer consultation? Yes. The ordering or rendering health care professional may request a Peer-to-Peer consultation after the case has been requested by calling evicore at 1-866-241-6603, Monday through Friday, from 7 a.m. to 7 p.m., ET. A Peer-to-Peer consultation may take place at any time on approved or denied requests. It can be scheduled or done real time. 24. How does a health care professional confirm a PA/MND determination for a patient? The ordering or rendering health care professional (if applicable) will receive a copy of the determination letter. The PA/MND determination may be viewed at www.evicore.com or the health care professional can call evicore at 1-866-241-6603 and select the Customer Service option. Nonparticipating health care professionals can call 1-866-241-6603 for a status of a PA/MND, Monday through Friday from 7 a.m. to 7 p.m., ET. 25. What if evicore does not have all of the necessary information to make a determination on a pre-service PA/MND request? If evicore does not have all of the necessary clinical information to make a determination, the PA/MND request will be pended for clinical review and the ordering or rendering health care professional will be given a case number. evicore will place the case on hold and request the additional clinical information needed to complete the review from the ordering or rendering health care professional s office. 6
26. What is the responsibility of the ordering/rendering health care professional? The ordering or rendering health care professional is responsible for obtaining the PA/MND and supplying all of the demographic and clinical information. If a PA/MND is not obtained prior to rendering services, claim payment may be delayed or denied pending completion of a post-service MND review. If the rendering health care professional, who is not the ordering health care professional, calls evicore to initiate a PA/MND, evicore will contact the ordering health care professional to obtain the necessary clinical information. The clinical information must be provided regardless if the ordering and the rendering health care professional are the same. In addition, the rendering health care professional is responsible for indicating if a co-surgeon is required for the requested Spine Surgery services. The health care professional must have the co-surgeon s name, TIN and Horizon BCBSNJ participation status. Refer to the QRG and follow the steps on how to check status of the PA/MND determination on HorizonBlue.com/musculoskeletal. The link is located at the bottom of the Spine Surgery tab. 27. How are health care professionals notified of evicore s PA/MND decision? evicore will email 2 health care professionals the approval status of PA/MND requests that are initiated through its web portal. evicore will fax notifications to health care professionals who initiate PA/MND requests by phone, and for those who initiate by web without a valid email registered on the web portal. 2 This functionality will only apply to health care professionals and their authorized contacts who have registered a valid email on the web portal. Prior to mid-november 2016, evicore will fax its decision. 28. After the decision is rendered, will a determination letter be sent to the health care professional and member? Yes. An approval letter will be sent to the ordering health care professional. A denial letter will be sent to the ordering health care professional, facility and the member. 7
29. Can an approved PA/MND determination be changed prior to the expiration date? Yes. A request to change an existing approved PA/MND determination can be submitted by calling evicore at 1-866-241-6603. The clinical staff will review the request and render a decision. evicore would not typically update an authorization after the service has been performed. They will review it prior to the expiration date. It must meet medical necessity criteria to update an authorization. 30. Are clinical trials part of this program? No. Clinical trials are not a part of this program. Please call Horizon BCBSNJ s Complex Case Management department at 1-888-621-5894 for clinical trials. 31. What is the time frame for evicore to render a decision for PA/MND? Non-urgent requests will be completed as soon as possible based on the urgency of the case, but no later than three business days from receipt of all required clinical information. Urgent requests will be completed as soon as possible based on the urgency of the case, but no later than 24 hours from receipt of the request. 32. Does a health care professional need a username and password to access evicore s application to request PA/MND? Yes. The health care professional should refer to the online QRG for instructions on how to obtain a username and password. The QRG is available on the Spine Surgery tab of HorizonBlue.com/musculoskeletal. 33. What is the difference between a case number and a PA/MND number? The case number is all numeric and assigned at the initiation of a request. A PA/MND number is not assigned until a final determination is made. 34. Is there a way to verify if a PA or MND number has been assigned to a request? Yes. Physicians or other health care professionals can logon to www.evicore.com and click Authorization Lookup. Select the member s Health Plan and enter the Health care professional ID, TIN, Office or Health care professional Name. These are required fields for this search. Enter the patient s ID and Date of Birth and click Search. 8
35. Does a PA/MND number expire? Yes. An approved PA/MND is good for 45 days. Physicians can log in to www.evicore.com and click Authorization Lookup for individual case details. 36. Is the PA/MND valid for the entire inpatient and outpatient stay? The PA/MND from evicore is valid for the eligible services relative to and occurred/rendered in the: Inpatient facility Outpatient facility Ambulatory surgical center Claims Disclaimer: The PA/MND does not supersede member benefits. An authorization does not guarantee payment of services. 37. How will this new program affect claims submission? Claims should be submitted in the same manner as before. Pre-service PA/MND review is recommended to avoid claims processing delays. 38. What happens to the claim if a PA/MND was not requested prior to the services being rendered? If a claim is submitted without obtaining a pre-service PA/MND, then the processing of the claim will be delayed until a PA/MND review can be performed and medical necessity is established. 39. What is required to expedite claims processing? To expedite claims processing, the following information is needed: An approved PA/MND determination number The appropriate HCPCS code for the specific procedure being billed The itemized date(s) of service 40. What happens if evicore does not receive the necessary information to make the determination on a post-service MND request? If medical records are not received in the required time frame, your claim will be denied and will remain denied until the requested clinical documentation is received. One fax attempt will be made by evicore to contact the ordering health care professional to obtain the necessary clinical information. If evicore is unsuccessful in obtaining the necessary clinical information, then evicore will request the necessary clinical information in writing and the health care professional will be given 25 days to submit the requested information. 9
Appeals 41. How does a health care professional dispute a PA/MND denial? Information on how to appeal a denial will be provided in the denial letter issued by evicore. Generally, a health care professional may dispute a denial that was based on medical necessity as follows: For members in plans that are part in the Musculoskeletal Program, health care professionals should call evicore at 1-866-241-6603. Submit written appeals to: evicore healthcare Attn: Appeals Coordinator 400 Buckwalter Place Boulevard Bluffton, SC 29910 Phone: 1-866-496-6200 Fax: 1-866-699-8128 42. How does a health care professional dispute a denial that is not related to a PA/MND? A health care professional may dispute a denied claims determination that is not related to a PA/MND (a decision not based on medical judgment) by calling Horizon BCBSNJ at: Physician Services: 1-800-624-1110 Facility Centralized Service Center: 1-888-666-2535 Members can call Member Services at 1-800-355-BLUE (2583) or the number listed on the back of their member identification cards. 43. Who can a health care professional contact for more information about a PA/MND appeal they submitted? For an appeal involving a PA/MND, call evicore at 1-866-241-6603. For a claim appeal not involving medical judgment, call Horizon BCBSNJ s Physician Services at 1-800-624-1110. 10